H&N: Stapling of pharyngeal pouch

Endoscopic Stapling of Pharyngeal Pouch

Indications

Treatment of a symptomatic pharyngeal pouch, especially if leading to aspiration pneumonia. This approach is now preferred to open techniques in most cases, as patients are usually elderly.

Procedure

The patient is positioned supine for pharyngoscopy. A mouth guard or wet swab is used to protect the upper teeth (if present). A diverticuloscope (which opens to allow distension of the area) is inserted into the post-cricoid area. The “bar” between the pouch and oesophagus is identified. An endoscopic stapler is used to simultaneously divide and seal the wall between pouch and oesophagus, making it into one cavity. A nasogastric tube is occasionally passed.

Length of procedure

Around 30 minutes if uncomplicated.

Complications

Pain Patients are likely to have a sore throat.

Bleeding

Dental/lip/jaw trauma If the patient is edentulous, the procedure is significantly easier. Ask patients about their dentition and document carefully.

Need for revision procedure

Perforation/mediastinitis The patient should be warned specifically about this possibility and its consequences. They would need to stay in hospital for at least two weeks, fed via a nasogastric tube. Occasionally a surgical repair (external neck wound) is required. Mediastinitis is rare but has a high mortality.

Post-operative management

A patient may go home the same day or stay overnight. Diet is gradually reintroduced, starting with water, then free fluids, then soft diet etc. Check the operation note for details.

Be wary of signs of perforation. Chest pain (may radiate to the back), tachypnoea, tachycardia, low-grade fever, dysphagia or surgical emphysema. These symptoms and signs should prompt urgent senior review.

TTO

Simple analgesia is usually sufficient. Some surgeons may prescribe a PPI. Check the operation note.